Prognosis Worsens For Shortage In Primary Care

This is TALK OF THE NATION. I'm Tom Gjelten, in Washington, sitting in for Neal Conan. It's bad enough that a visit to the doctor's office can be expensive. Maybe you worry about the quality of care you'll receive. But that's not all. A common complaint these days is the length of time we have to wait before we see someone who can help us.

There's a doctor shortage in this country, and it's bound to get worse. The new health care law expands coverage. There'll be more patients waiting to see fewer and fewer doctors. The Association of American Medical Collages projects that by 2015, in just three years, we'll be 63,000 doctors short of the number we need. And that number could double by 2025.

We want to hear from primary care providers, doctors, nurses, nurse practitioners, physician assistants. What do you think is behind this shortage? Our number is 800-989-8255. Our email address is talk@npr.org. And you can join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.

Later in the program, Max Fisher of The Atlantic shares his survey on travel guides for foreigners in America. But first NPR health policy correspondent Julie Rovner joins us in Studio 3A. Hi, Julie.

JULIE ROVNER, BYLINE: Hi.

GJELTEN: So how serious is this primary care situation in the country right now?

ROVNER: It's pretty serious, and it's not a surprise. It's been serious since before the health law was passed. It's mainly serious because of the demographic shift. You've got the baby boom generation rapidly aging, rapidly aging into Medicare eligibility.

GJELTEN: And needing more health care.

ROVNER: Exactly, as you age, you need more health care. Obviously, you need more frequent health care and more intensive health care. So we knew that we were going to be looking at a health care shortage. The other problem with that is that the health care workforce itself is aging.

Remember a lot of them are also baby boomers. So at the same time, you have a generation that's going to need more health care, you have more health care professionals who are going to be retiring. So you have sort of a dangerous combination there. You're going to have a smaller generation behind this generation to take care of this baby boom generation, and you're going to have this baby boom generation needing more care.

Then you layer on top of that the Affordable Care Act, the 2010 health law, that's going to cover an additional now they're saying 30 million people, and you've got a big mess. On the other hand, the Affordable Care Act knew about this. I mean, the people who put that together saw there would be a problem.

There's an entire - one of the titles of that act is - talks about expanding the primary care workforce.

GJELTEN: Well, let's take these things one piece at a time, Julie, OK, so as not to get overwhelmed. First of all, why are not more people going to medical school? Why aren't we graduating more doctors? If there's such a demand, you know, you would think this would be an attractive profession to go into, why are we not seeing more doctors becoming - graduating from medical school?

ROVNER: Well, we are. There are actually several new medical schools. That's not the bottleneck. We are indeed graduating more doctors from medical school. What there is a shortage of are residency positions. So the bottleneck is in the residencies. In 1997, Congress capped the number of residencies that could be funded by Medicare as a cost-cutting provision.

The problem is there are too many of these graduating MDs who are going into specialty care and not primary care.

GJELTEN: They all want to be dermatologists.

ROVNER: They all - that's exactly correct. They all want to be dermatologists. The ones who don't want to be dermatologists want to be radiologists. The ones who don't want to be radiologists want to be emergency room doctors because they can set their own hours.

People don't want to go into primary care. It doesn't pay as well, it's much more stressful, and it's - the lifestyle is really not that conducive to, you know, having a family, trying to live a, you know, a structured life, and that's not what today's medical student wants to do. Plus you graduate with hundreds of thousands of dollars in student loans. It's difficult to pay those back.

All the incentives point these graduating medical students away from going into primary care.

GJELTEN: And where is the situation the worst?

ROVNER: This situation is the worst in the places that people would least like to live, in rural areas in particular, in the inner cities, in places that the government has designated these health care professional shortage areas. So, you know, if you think about where there are not a lot of people and where it's maybe, you know, not that pleasant, where it's really cold in the winter or really hot in the summer, or there really aren't a lot of big cities. That's where it's hardest to recruit doctors.

GJELTEN: So what is happening? Is there any way to provide incentives for doctors to choose primary care or family medicine as their specialty, as their practice?

ROVNER: Yes, there is. And that's what was in - that's exactly what the law tried to do. One of the things is you can give graduating students or residents loan forgiveness. You can say hey, you've got these hundreds of thousands of dollars in medical school loans, we will help you pay off your loans if you agree to come serve in these under-served areas. If you agree to stay in these under-served areas, we'll pay off even more of your loans. That's one of the ways.

They can give special dispensations going in for people who will - who agree to become primary care practitioners. A lot of the money in the Affordable Care Act went to beef up programs that train primary care providers, not just doctors but nurse practitioners, physician assistants, what we call mid-level providers because remember primary care doesn't necessarily have to be provided by someone with an MD after their name. And that's going to be one of the ways that people who study in health policy think that this shortage will be alleviated, not just by having more doctors but by having doctors work in teams with other less highly trained specialists who can deliver good primary care. There's lots of studies that say good primary care can be delivered by people like nurse practitioners, by physician assistants, by nurses.

GJELTEN: And we're also seeing more doctors coming from other countries, who have even, in some cases, I imagine, been trained in foreign medical schools.

ROVNER: Well, that's always been the case. And again, you know, that does - you get two things. You get doctors coming from other countries who are already trained, are already MDs, and you get doctors coming from other - from foreign medical schools, these foreign medical graduates, who are coming and taking U.S. residencies. And in fact many of them are filling these primary care residencies that the U.S. medical school graduates don't want because they're all taking the specialty residencies.

GJELTEN: You know, Julie, I was talking to a doctor friend the other day who had actually - was getting out of medicine. And she was getting out of medicine because she said it was too stressful. She said that in her practice, she needed to see something like 40 patients a day in order to cover overhead and everything else. How serious are some of these quality-of-life issues for doctors, and are doctors who have been trained, are they actually leaving the profession now because they find it too stressful or too difficult or not sufficiently remunerative?

ROVNER: It's a really tough time to be a doctor. You know, people don't have a lot of sympathy for doctors, many of whom make, you know, obviously - almost all of whom make six-figure salaries, many of whom make upper six- and seven-figure salaries. But it really is - it is definitely a time of transition.

Insurance companies put a lot of pressure on doctors. There's a lot of change in how the practice of medicine is working. There's a lot to keep up with, and a lot of doctors are actually selling out their practices to hospitals so they can have a little bit more, you know, financial security, if you will, trying to figure out what it is that they're going to do.

But, you know, for doctors just starting out, it is really difficult to know, you know, just how you can do this financially, you know, have some financial viability. As I said, if you're paying off enormous student loans, trying to make a go of it, trying to do your patients well. I hear a lot of doctors worried about whether they can give patients enough time to really legitimately take care of them.

GJELTEN: Well, let's hear from some providers. Steve is on the phone right now from Idaho Falls, Idaho. Good afternoon, Steve, thanks for calling us.

STEVE: Hi, thanks for talking with me. I'm a big fan.

GJELTEN: Good. All right.

STEVE: So, you know, I'm - neurology is sort of close to primary care. We don't have...

GJELTEN: Neurology, you're a neurologist.

STEVE: Correct, I'm a neurologist, and we don't really have a lot of procedures. And as I was mentioning to the call screener, you can be a dermatologist and take off a mole in 15 minutes and make more than I would make in an hour with a patient face to face. And so when you're coming out with that $300,000 in student loans, it's almost crazy to go into a non-procedural specialty because how are you going to pay it off. It's quite unfortunate.

GJELTEN: Julie, do you have a comment on that?

ROVNER: Yeah, you know, one of the big issues, and this is an issue that's rolling around again, is the payment system. Most payment systems are based off of what Medicare pays. Medicare revamped its payment system in the late 1980s to try and move it a little bit away from this emphasis on paying more for procedures and less on what they call cognitive activities, doctors who actually think about they do as opposed to actually cutting you or, you know, doing something with an instrument.

And it worked for a little while, and now it's gotten all out of whack, and Congress is at the point where every year it has to put another patch on it to prevent these huge cuts from going into effect, which simply adds to doctors' stress levels. If Congress doesn't act by the end of the year, doctors are - this is all doctors who take Medicare are looking at almost a 30-percent cut. So that's adding to the entire stress of all of this.

GJELTEN: Well, let's hear from another doctor. Bill(ph) is on the line from Delaware. Good afternoon, Bill, thanks for calling.

BILL: Hi, thanks for having me; I love the show.

GJELTEN: Good.

BILL: So I'm an ENT proceduralist: I like to cut. That's why I went into it. But...

GJELTEN: An ENT, OK.

BILL: Ear, nose, throat. I cut out tongue cancer and stuff like that. But I was calling because the last time I looked, which was a few years ago, and I may be inaccurate, there were significantly more residency slots total then medical school graduates in the U.S. total. There were 16,000 graduates, say, and 20,000 residency slots, and hence most rural hospitals in particular had to hire foreign medical school graduates to fill their residency slots.

I'm wondering if that's still the case. If it is, the solution is despite new medical schools, there's more yet medical schools, and one way to fill a need for primary care in underserved areas, which I think is done in most industrialized countries, is to make education a lot cheaper, perhaps even free with government subsidy, in exchange for a service obligation.

If you're going to have a free education, you have to do five years of primary care in rural Delaware, for example. I just wanted to put that into the discussion.

GJELTEN: OK, Bill, thanks for the call. Does that sound right, Julie?

ROVNER: No, well actually because there are new medical schools, there are very - there are fewer residency slots that go what's called unmatched. There's this very complicated matching system, it's actually very elegant but also very complicated, where hospitals and medical students basically choose each other, and then there's a - for people who don't get matched, there's a rematch system that goes ahead.

But because there are new medical schools, it is no longer the case there are a lot of unfilled residency slots. There are still some, and they are still filled by foreign medical school graduates, as we talked about earlier, but it is increasingly less, and there is going to be, I believe soon, a problem where there will be almost none.

GJELTEN: Well, we have a private health care system in the United States, not a government health care system, and that means that the market is always going to rear its head and exercise its own force on supply and demand of care providers.

We're talking with NPR's Julie Rovner about the shortage in primary care practitioners. If you're one, a doctor, a nurse, a physician assistant, we'd like to hear from you. What do you think is behind the shortage? 800-989-8255 is our phone number. The email address is talk@npr.org. We'll have more in a minute. I'm Tom Gjelten. This is TALK OF THE NATION, from NPR News.

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GJELTEN: This is TALK OF THE NATION from NPR News. I'm Tom Gjelten. We're talking today about a shortage of primary health care providers in the U.S. More medical students are going into specialty fields these days, plus many nurses are retiring; nurses make up the oldest workforce in the nation. In communities around the country, especially in rural areas, residents are trying to entice doctors to come practice in their towns, but the relatively low pay and long hours for family doctors make it a tough sell.

Primary care providers, doctors and nurses, we want to hear from you. Why do you think we have such a shortage? Our number is 800-989-8255. Our email address is talk@npr.org. And you can find us on Twitter @totn. NPR's health policy correspondent Julie Rovner is here with me in Studio 3A, and joining us now here is Ann Davis. She practiced as a physician assistant for 20 years. Now she's senior director of state advocacy and outreach for the American Academy of Physician Assistants. Welcome to the program, Ann.

ANN DAVIS: Thanks so much.

GJELTEN: So we've been talking about this shortage of doctors as primary care providers. To what extent can physician assistants help fill that demand, and have we seen an up tick in the demand for physician assistants as a result of the doctor shortage?

DAVIS: You know, we really have. And I guess whenever we think about a scarce resource, there's sort of three ways to think about that. You can increase supply, which you talked about a minute ago, of physicians. You can use the scarce resource more wisely, or you can actually reduce demand. And I think the second two are where PAs are particularly critical.

We can certainly help to extend the reach of physicians by that team practice that we really look toward, that is not everything that a physician would do, certainly a primary care requires the physician's full talent and training. So PAs, as part of a physician-PA team, really can extend the reach of physicians.

And then in terms of decreasing demand, if the PAs are available to do some health promotion, some exquisite coordination of care so that you decrease readmissions and that sort of thing, that helps address the physician shortage also.

GJELTEN: Where are some places physician assistants are working right now? I know that there's a big increase in minute clinics. Are they staffed by physician assistants? And where are some of the other places you see physician assistants being used effectively?

DAVIS: Certainly, we're really trying to find PAs go where the patients are. So your reference to retail clinics is certainly a good one, and we like those particularly when they're well-integrated with other health systems so the patient can receive seamless care, wherever they're being seen.

We certainly see a lot of PAs that are working in specialties are particularly underserved, as well as primary care, for example nephrology. So patients that have chronic kidney disease, the nephrologists can certainly be more effective if there's a PA there, too, to do some of the coordination of care, making sure that the grandma and the patient and the vascular surgeon are all on the same wavelength in terms of what needs to happen for the patient.

GJELTEN: You know, not too long ago, I had a pretty serious cut that required surgery, required going to an emergency room. And I was sutured by a physician assistant who did nothing all day long but sew up cuts. And I have no doubt that she was a lot better at it than an emergency room attending physician would have been because this was her specialty, and it didn't really require really advanced training, right?

DAVIS: That's right, and that's certainly a good use of the physician's time, too, to make sure that somebody who does something all day long does it very well, is available to take care of you and then with a doctor available if that's what's required.

GJELTEN: So Julie was talking about the shortage of doctors and how too few doctors are going into primary care. Are enough people being trained as physician assistants, or do you also see, you know, too few people going into this field?

DAVIS: This field is rapidly growing. Six thousand new PAs enter the workforce every year, and one in three practice in primary care and stay in primary care. We also find that because PAs are all trained as generalists, they're able to provide some of that coordination primary-care-like services even when they're in a specialty practice.

GJELTEN: What's the connection, what's the relationship between the medical - the doctors' profession and physician assistants? I mean, you have talked about how they work together. Has there been any, you know, sort of turf protection by doctors who are wary of seeing physician assistants take over some of the duties that they have traditionally performed, for example?

DAVIS: You know, I think early on that was the case. Now we're really seeing an emphasis on everybody's part on team-based care. Medicine just has to be a team sport. And physicians, particularly ones that are newer physicians, who trained with PAs and get out of their residency program and look around and say OK, now where's my PA so I can get to work, that's what you see more now.

So I think everybody's appreciating sort of the magnitude of the problem that we face with the health care workforce.

GJELTEN: Is there any way that you can produce more physician assistants? For example, what's the situation - tell us first where physician assistants are trained. Are they trained in nursing colleges? Are they trained in medical schools, or is there some other venue of training for physician assistants?

DAVIS: Right, there are about 164 accredited PA programs right now in the country, and more are opening. PA programs are at medical schools, teaching hospitals. There's one in the military. They're all accredited by the same organization. In order to enter a PA program, you have to participate in about three years of biomedical sciences before - sort of like pre-med preparation, and then you go to a PA program, which is about three academic years in length, 27 months, a combination of classroom work and clinical work, supervised clinical practice.

So PAs can enter the workforce more rapidly. It takes a long time to train a fully qualified physician, but PAs with a master's degree can enter the workforce more quickly.

GJELTEN: And the pay is obviously a big consideration. You know, how does the pay for a physician assistant compare to a nurse on one side or a physician on the other side?

DAVIS: You know, I'm not sure really sure about on the two sides, but the average median salary for PAs is about $90,000 a year. So it's certainly a well-compensated profession but not like physicians, and that's fine.

GJELTEN: Well, they don't have the physicians have to go through.

DAVIS: That's right, absolutely.

GJELTEN: They don't come out with the bills, the debts that physicians do.

DAVIS: Exactly right.

GJELTEN: Let's go now to Susan(ph), who's on the line from Aiken, South Carolina. Good afternoon, Susan, thanks for calling us at TALK OF THE NATION.

SUSAN: Hi, thanks for taking my call. I'm so excited that you're talking about this. I work in women's health as a nurse practitioner, gee, since 1984. And it seems to me that some of the problems we face, certainly as you're saying, the nurses are aging out, and not everybody is wanting to follow in our footsteps. But functioning as a primary care provider in GYN is not uncommon because quite often the GYN is the only provider that a woman sees.

And I feel like we have a problem continuing to provide the level of care we want to provide because we've got to meet the numbers crunch. The insurance reimbursement, Medicare reimbursement continues to go down, and we are expected to see more and more patients by the numbers, but the patients still expect that warm, fuzzy kind of care that you get to give when you don't have to limit your visit to 15 minutes or (unintelligible) they want to be able to know that you know about their family, not just their family health history but about their family life history.

And it's hard to make all of that, sort of, come together in a way that's satisfying for us as providers, as well as for the patient to feel like they've been taken care of, not only in their physical need of the day but to feel like they got those other needs met, as well.

GJELTEN: OK, Susan, thanks for the call. And what about those concerns that Susan is raising there?

DAVIS: They're real. I think that if - I'm a little - I'm quite hopeful that some of the new models of care will help us with that. For example, now that Medicare covers a welcome to Medicare visit, that really lets you establish that relationship and get compensated for it. Also, I think that accountable care organizations may be moving to places where we're not, as Julie mentioned, paying actually for piecework in terms of medical care but really looking at outcomes and value.

And I think PAs and nurse practitioners have a fabulous role to play there.

GJELTEN: I want to raise this question from both of you. Marian(ph) in Louisville, Kentucky, says: I know there's - this is an email. I know there's a big push for primary care physicians. Studies have shown that patients do better and cost less when taken care of by - when taken care of by physicians who actually know what they're doing, the specialists.

We do need primary care providers but not nearly as many as are being proposed. After all, the population is aging, and the elderly need more complex care. Julie, do you have a thought on that?

ROVNER: Yes, I'm not sure what studies she's referring to, but, you know, one of the things that certainly has been seen from studies is that having care coordinated by someone is one of the answers. And, you know, one of the new models that I think you were referring to is something called the medical home, where there will be someone not necessarily - there will be a doctor at the head of the team, but there'll be someone, usually a nurse practitioner or a PA, who will help coordinate everything and keep track of, you know, all the different types of care that a patient is getting from the various specialists.

And that will prevent things like drug interactions if you're going to six different doctors and sometimes, you know, no doctor has any idea all of the medications a patient is taking because there's so many different doctors prescribing them, and they may have some kind of interactions.

So this would be the idea that there would be someone who actually is looking out for everything that a patient - all the kinds of medical interventions that a patient has going on. That's the idea. That kind of care has been tested. It is intensive. It's labor intensive, but it's - but the outcomes tend to be better, and if you can make it work, it tends to be more successful. It's a better quality of life, both for the patient and for the health care professionals.

GJELTEN: Well, Ann, I'm sure you would agree that patients who need to see a specialist - not a primary care provider - should see a specialist. And patients who should see a physician, as opposed to a physician's assistant, should be able to see a physician.

DAVIS: Absolutely right. We're all about team care, and certainly finding the right provider at the right location for the patient. That's how you maximize everything, including (unintelligible).

GJELTEN: Sure. Let's go now to Marcus, who's calling us from Webster City, Iowa. Good afternoon, Marcus. Thanks for calling TALK OF THE NATION. You're on the air.

MARCUS: Hello.

GJELTEN: Your comment? Yeah.

MARCUS: I just had a quick comment. You know, you're talking about the shortage of physicians and nurses and, you know, health care providers. I just graduated from nursing school, and what I found to be most interesting and most challenging is that as a new nursing graduate, it's extremely difficult to find a position right now available in - it seems like anywhere. I know that I'm not alone in this. A lot of people I graduated with are the same way. It just seems that every position that I apply to or I look into everywhere wants experience.

I've heard back from a lot of places saying that because I don't have any experience, that, you know, that's the reason why, you know, they're going to pursue other candidates and stuff. And so I just wonder, to your panel, you know, as a new health care, you know, provider in a nursing role, what could I do to, you know, make myself more attractive out there?

GJELTEN: Well, that's an interesting comment, Marcus, because I've always heard that there's a great job market for nurses around the country. You're finding - at least at the entry level - that's not necessarily so true, huh?

MARCUS: Right. Right. I mean, you know, it seems that every position I've applied to or even looked into, it's always, you know, we require two or more years of experience, and we want all of these certifications. And, you know, one of the reasons why I decided to pursue nursing was because, you know, growing up, I always was told, oh, it's a very safe career and...

GJELTEN: Yeah.

MARCUS: ...it would be a smart thing to go into.

GJELTEN: Well, thank you very much, Marcus. Julie, I would think that if there really is a nursing shortage, some of these experience requirements are likely to be loosened a little bit. If communities really do need more nurses, they may be forced to accept nursing graduates with less experience than those communities may ideally like to have.

ROVNER: Yeah. Well, I actually have heard in the last year or so that - particularly newly graduated nurses - are having trouble finding positions. And, you know, some of them are having to take temporary positions, or having to go to areas where there are more shortages. And that's obviously the answer to how you find a job in nursing. I think, in fairly short order, these nurses will be absorbed. But, yes, right now, there does seem to be a small glut of nurses, of entry-level nurses.

GJELTEN: Julie Rovner is health policy correspondent for NPR News. You're listening to TALK OF THE NATION, from NPR News.

And let's go back to the phones, now. Let's go to Eric, who's on the line from St. Louis, Missouri. Good afternoon, Eric.

ERIC: Good afternoon. Thanks for taking my call. I'm a surgical subspecialist. And I think that while under-compensation of primary care doctors is really a problem in one aspect of the shortage, I think it's going to be very hard to just financial incentivize people to go into primary care.

I think the biggest reason people choose the specialties they do is what fits their personality. Most surgeons I know - myself included - would make really lousy primary care doctors and not be very happy. I think the same is -the reverse is true, too. Most primary care docs would be pretty unhappy surgeons. And people gravitate towards those practices that fit their personality and their way of problem-solving and specific skill set.

I think money is certainly part of it, but I know a lot of physicians who are happy in their specialty and aren't looking to change just because other specialties pay more.

GJELTEN: Yeah. Well, I'm sure that that does, as you say, apply to a lot of physicians. I have to wonder whether there are other medical students who would be swayed by monetary incentives.

I want to point out, we have an email from Allen(ph) in San Francisco, who says: There needs to be a better incentive for medical students such as myself to enter primary care. Either shorten our training from four years of school to three years of school, or provide better compensation for our work. Ann...

ROVNER: That three years of school to become a primary care doctor...

GJELTEN: Yeah, Julie.

ROVNER: ...is happening in a couple of places.

GJELTEN: Really?

ROVNER: It is. Because, you know, the fourth year of medical school is mostly rotations, anyway. It's mostly clinical. It's not classroom experience. It's usually clinical experience. And there are a couple of places experimenting now with, actually, a three-year medical school degree to go into primary care.

GJELTEN: And that - and you still come out with a regular MD.

ROVNER: Yup, and a lot less in the way of loan expenses.

GJELTEN: Well, it seems that - you know, one of the things that we've seen, Ann Davis, in the whole field of medicine is greater specialization in terms of types of - I mean, I remember going to see a dentist when I was a kid. You just saw a dentist. You didn't see a dental hygienist or a dental assistant. And the same thing at a doctor's office now: There's a greater range of capabilities and skills and proficiencies that can be tuned to patient's particular needs.

DAVIS: I think that's right, and I think it's good. I think that if you're going to really treat patients in the way that they should be treated, you're going to find the person that connects with them best for the issue that they have.

For example, some pediatric practices now have a lactation consultant, which may be exactly the right thing to have in that practice. That's different than it was a few years ago.

So I think incorporating the skill sets and making sure that the team is well-coordinated is going to be a big change. And I think the (unintelligible) mechanisms will help with that. I think the idea of moving to medical homes, accountable care organizations and even things like the Independence at Home demonstration projects I think will make a difference, too.

GJELTEN: What's the situation in the training institutions? Is there a shortage of nursing teachers, just as there is a shortage of nurses? Is there a shortage of educational personnel in those facilities that train physician assistants?

DAVIS: There are. And that's a worry, I think, for all of us. You know, you mentioned - if I can shift for just a quick minute. You mentioned incentivizing people, or paying for folks to go into primary care. Just, like, last week, Secretary Sebelius announced a training program for veterans to go into PA programs. That's great.

Veterans are more likely to come from small towns. They're more likely to return. And statistically, for PAs, veterans are more likely to stay in primary care, which is a real boon.

GJELTEN: Ann Davis practiced as a physician assistant for 20 years. Now she's senior director of state advocacy and outreach for the American Academy of Physician Assistants. She joined us here in Studio 3A. Thank you very much, Ann.

Coming up, if you have read a guidebook for a foreign country, you might have learned the Japanese love to talk about the weather, British people call french fries chips. Now we're going to learn what travelers to the U.S. learn about us, after a short break.